Can cirrhosis cause anemia?

Does Cirrhosis Cause Anemia?

Yes, cirrhosis frequently causes anemia through multiple pathophysiological mechanisms, with prevalence increasing as liver disease severity worsens. 1

Prevalence and Severity Relationship

• Anemia affects 40-66% of patients with cirrhosis, with prevalence directly correlating to disease severity 2
• The prevalence increases significantly with Child-Pugh score: 26.5% in Class A, 59.2% in Class B, and 69% in Class C 3
• Anemia is present in 62.4% of decompensated cirrhosis patients compared to only 18.8% in compensated cirrhosis 3

Primary Mechanisms of Anemia in Cirrhosis

Portal Hypertension-Related Bleeding

• Bleeding from esophageal varices, portal hypertensive gastropathy, and gastric antral vascular ectasia are major contributors to anemia 1, 2
• Both acute hemorrhage and chronic occult blood loss from portal hypertension lead to iron deficiency 1

Eryptosis (Premature Red Blood Cell Death)

• Elevated bilirubin and bile acids induce eryptosis, causing premature erythrocyte death 1
• This creates a vicious cycle: increased red blood cell destruction generates more bilirubin, which further induces eryptosis 1
• Patients with hyperbilirubinemia demonstrate significantly lower red blood cell counts and higher reticulocyte counts 1
• The liver's Kupffer cells, which normally clear damaged erythrocytes, become overwhelmed in cirrhosis 1

Nutritional Deficiencies

• Iron deficiency is common due to chronic blood loss 1
• Folate (vitamin B9) and vitamin B12 deficiencies contribute to macrocytic anemia 1, 2
• Vitamin B6 deficiency also plays a role 2
• Malnutrition from chronic liver disease and alcohol use exacerbates these deficiencies 4

Bone Marrow Suppression

• Direct alcohol toxicity suppresses erythrocyte production 1, 4
• Hepatitis B or C viral infections can cause bone marrow aplasia 1, 5
• Chronic inflammation associated with cirrhosis impairs erythropoiesis 4

Hiperesplenismo and Sequestration

• Splenic sequestration from portal hypertension causes thrombocytopenia in 80% of cirrhotic patients and contributes to anemia 1
• Reduced thrombopoietin production affects megakaryocyte and platelet production 1

Hemolysis

• Acanthocytosis (spur cell anemia) can occur in advanced alcoholic cirrhosis, causing hemolytic anemia 4

Clinical Impact on Outcomes

• Anemia is an independent risk factor for hepatic decompensation and mortality, particularly in compensated cirrhosis (adjusted HR: 4.91) 3
• Anemia predicts acute-on-chronic liver failure development 6
• Increasing hemoglobin levels is associated with improved transplant-free survival (HR = 0.72 per g/dL increase) 6

Common Pitfalls to Avoid

• Do not assume anemia is solely from acute bleeding - most patients with advanced cirrhosis already have baseline anemia from multiple chronic mechanisms 2
• Do not rely on post-procedural hemoglobin alone to diagnose occult bleeding without a pre-procedural baseline 2
• Do not overlook iron deficiency anemia in early cirrhosis - in compensated cirrhosis and Child-Pugh A/B patients, 73-80% of anemic patients have iron deficiency as the primary cause 3